• Luciano Ferreira de Holanda, PereiraBenedito Jamilson ABJADepartment of Neurosurgery, Hospital Antônio Targino, Campina Grande-PB, Brazil; Department of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo-SP, Brazil. Electronic, Rafael Rodrigues Holanda, José Targino Neto, de HolandaCarlos Vanderlei MCVMDepartment of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo-SP, Brazil., Miguel Giudicissi Filho, de OliveiraNathalia Ribeiro CunhaNRCDepartment of Dentistry, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo-SP, Brazil., and Jean G de Oliveira.
• Department of Neurosurgery, Hospital Antônio Targino, Campina Grande-PB, Brazil; Department of Neurology and Neurosurgery, Federal University of Campina Grande-PB, Brazil.
• World Neurosurg. 2016 Jun 1; 90: 420-429.

ObjectiveThe objective of this study is to present a case series of nonmissile penetrating (NMP) injuries and to establish a workflow for an uncommon mechanism of traumatic head injury through the analysis of each case, classification of the type of lesion, management, and outcome score at follow-up.MethodsFrom January 1991 to December 2008, 36,000 patients presenting with traumatic brain injury (TBI) were admitted in the Department of Neurosurgery, Hospital Antônio Targino, Campina Grande-PB, Brazil. From these patients, 11 presenting with lesions caused by NMP objects were selected.ResultsAmong the 11 patients, 9 were men and 2 were women. Their ages ranged from 7 to 74 years old (mean age ± SD, 29.1 ± 22.99 years). All patients underwent neuroradiologic evaluation. The entry point was classified as natural (orbit) or artificial (skull transfixation), and we also divided the patients presenting with secondary parenchymal or vascular damage from those presenting with only lesions caused by the primary penetration into the cranium and meninges. All patients were neurosurgically treated with removal of the foreign body through craniotomy, except the patient whose object (pen) was removed without craniotomy with local anesthesia. Glasgow Coma Scale (GCS) score on admission was a statistically significant factor on prognosis, and any patient who presented with a GCS score of 15 evolved satisfactorily, and there were no deaths in this group of patients (P = 0.04).ConclusionsTBIs caused by NMP objects are unusual and caused by aggression, self-inflicted harm (in the case of psychiatric patients), and accident. The foreign body may enter into the skull through a natural hole (orbit, nose, mouth, or ear) or crosses the skull, causing a fracture and creating an artificial hole. Preoperative neuroradiologic assessment is paramount for the correct neurosurgical approach. The main prognostic factor for these patients is the GCS score at admission.Copyright © 2016 Elsevier Inc. All rights reserved.

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